Prescription Sports

RUNNING ON A HARD SURFACE

Running is one of the most popular sports in the world. This not only covers marathons and track and field running – running is also part of the training in virtually all other sports, including soccer, rugby, handball and triathlon. Running is a very efficient method for maintaining or improving cardio vascular, respiratory and musculo-skeletal fitness and increasing the structural strength of the musculo-skeletal system. It is also an effective way of improving the tensile strength of the lower limbs. Modified levels and intensities of running can also be used as alternative training for most athletes with certain types of injuries. However, before running on a hard surface, such as roads or astroturf, the patient must be able to withstand the repetitive eccentric impact to the lower limbs, as each stride will create an impact force of five to ten times body weight for a fraction of a second. Since each stride stresses the same structures, their tensile strength and endurance lie between positive training effects and injury.

Running can be over a distance, in a variety of intervals or as a varied running-jogging-walking programme. The intensity and the distance must be proportionate to the runner’s ability and objectives. Running on a hard surface mainly loads the lower limbs, where 90 per cent of running injuries are found. The most common error an inexperienced runner makes is to run too fast and too long too early, so that training causes new injuries instead of Despite its popularity, running on asphalt is very demanding promoting the healing of another. It is important to use common sense when prescribing hard-surface running. For an inexperienced runner the safest way to build up performance after an injury is a slow and steady running tempo,
including a proper warm-up.

The best test of improvement in running capacity is repeatedly to measure the runner’s effort and time in a simple test race. For a fairly unfit but otherwise healthy person who wants to improve their general fitness and aerobic performance, running can be recommended as part of a progressive programme. From a reasonable starting point, such a programme would usually increase less than 15 per cent in distance and intensity per year. An elite marathon runner with an over-use injury may simply reduce their running time from two hours to one hour per day; not pushing over the pain threshold but gradually increasing the time day by day. A 130 kg rugby player, even though extremely fit, is not a good candidate for long-distance or road running. Their knees will undoubtedly say ‘no!’ to this madness. This type of exercise also cannot be recommended for obese or generally unfit recreational athletes or people with structural knee or hip problems, such as osteoarthritis. A reasonable running tempo that can be maintained for 30 minutes is essential for a persistent training effect. Runners should aim for a pace at which they can chat with a
running mate while breathing almost normally; this is equivalent to 60 to 70 per cent of maximum aerobic capacity. The subjective experience of running is far more important than the heart frequency, which is not directly proportionate to the runner’s feeling. Even with the same heart frequency, for example 160 beats per minute, running can be very easy one day and very uncomfortable the next.

The subjective experience of training is very important for a non-runner’s motivation. Since the surface is consistent for each stride the same structures in the lower limbs will be put under repeated stress. While this leads to a functional adaption of the strength of the structures it can also lead to injuries in the short term. This also highlights the importance of proper, comfortably fitting running shoes with a cushioned sole, which can reduce the impact from touchdown in the stride, distribute the forces and provide stability to the ankle and foot. The commercial running shoe market is un fortunately mainly fashion-orientated and new models are pumped out every six months. Despite improved biomechanical knowledge, which manufacturers claim has revolutionised the market, and lighter high-quality materials and technology within the sole to compensate for different individual factors, modern running shoes do not last long. It may also be questioned whether they have reduced the incidence of injuries. When Arthur Lydiard introduced his running shoes around 1970, I could hardly run out a pair in two years’ intensive running, and new soles could be reattached at least once before the shoe broke up. Today, most running shoes are worn down by regular running within 6–12 months. Regular runners will soon find their own style, but might have more trouble getting a consistent style of footwear.

Most running injuries are caused by training errors. In some cases, bio -mechanical factors, such as excessive pronation, contribute to the injury. If such factors are suspected, an experienced podiatrist may be able to help.

Running on a hard surface is a very efficient training method but as a primary alternative training form for the untrained, overweight or those with major injuries to the lower limbs, it should be prescribed with care.

RUNNING ON SOFT SURFACES

Running on soft surfaces maintains or increases fitness and tensile strength of the lower limbs and with less eccentric impact compared to running on hard surfaces. A well-balanced running programme over moors, in parklands or in forests can be recommended as a primary alternative training for most runners and other athletes with over-use injuries, even those of the lower limbs. People with mild or moderate knee or hip osteo-arthritis, who struggle to run 500 m on the road, may be able to jog a 5 km orienteering course without adverse effects.

A varied and soft running surface creates a lower impact on the musculo-skeletal system, due to the longer time for shock absorption from each stride and the wider distribution of forces over the kinetic chain. On the other hand, the runner is forced to work harder, from a muscular point of view; they need to lift the knees higher when running uphill or over obstacles on the ground like vegetation. This consumes more energy and, all in all, uses more muscle groups than running on hard surfaces. (Running in forests consumes up to twice as much energy per kilometre as road running.) Running on soft surfaces is less demanding for the lower limbs but, due to the increased energy demand, puts more stress on the cardiovascular and respiratory system and so is good for weight reduction and general fitness.

There are risks in the prescription of this type of training. Over uneven terrain, the risk of ankle sprains and falls increases. Even though temporarily running on soft surfaces can be recommended for a marathon runner with over-use injuries of the lower limbs, they must be aware of the increased risks. Proprioceptive ankle training and core stability training must accompany alterations in running type. Older athletes, or fragile patients with osteoporosis or disabling injuries, may jog or walk on softer surfaces instead of running.

WALKING

Walking has been recommended by doctors for rehabilitation since the eighteenth century. Long walks were used as regular training by established marathon runners as long ago as the nineteenth century. It is a natural way of exercising, which does not require any special preparation, equipment or clothing (except clothes suitable for the climate). This low intensity and low-impact exercise produces increased tensile strength of the lower limbs for a relatively low cardiovascular effort. It is a training form that can be prescribed to almost everyone, except people on crutches who cannot bear their weight fully. Even very unfit, elderly or obese patients may benefit from walking slowly and for reasonable distances. It is well documented that ageing of muscles and skeleton in the locomotor system can be altered with low-intensity regular physical activity.

This kind of training can be done in the same way as running, with varying distances and speeds. While Olympic athletes can walk 10,000 metres in less than 40 minutes, most people wouldn’t be able to run it in that time. To increase energy consumption at low walking speeds, a rucksack or weight belt may be carried. Walking in forest, parklands or the beautiful countryside is an extremely popular weekend activity for a great many British people: a day out can be a great experience as well as excellent exercise. To help city dwellers and single elderly people who may not dare to walk alone, walking clubs are springing up in most cities. These clubs organise walks in small groups, which also has a A dog is an excellent incentive for taking a 30-minute walk every day positive social effect. We should not underestimate the effect of daily walking, even in big cities. A modern shopping or outlet centre can provide kilometres of walking. Red ‘SALE’ signs will enhance the pace of walking for most visitors! The effect of this kind of exercise for general health is substantial – as long as we walk somewhere, it doesn’t matter how or where.

WATER EXERCISES AND WATER RUNNING

Water exercises may be prescribed as rehabilitation and alternative training for most injuries, unless the person has wounds, eczema or other skin disorders. Usually, a surgical wound requires two weeks of healing and any stitches to be removed before starting water exercises, due to the risk of infections. Water exercising allows an athlete to maintain or improve aerobic and anaerobic capacity if suffering injuries that do not allow full impact on hard surfaces. Water running and work-out exercises can be used as alternative training for most types of injuries. An athlete who is immobilised in one limb can have a plastic brace, which allows water training, instead of a plaster one. Water exercising can improve the endurance and flexibility of asthmatic athletes and people with different disabilities. It is a superb alternative training method for disabled or elderly patients, where large muscle groups can be trained without impact. The low resistance of water creates a low eccentric impact on the lower limbs.

In principle, everything you can do on a floor you can do in water. It is important to devise a programme – not just jump in the water and tumble around. Use either a floating device or jacket that allows the athlete to concentrate on the exercises, rather than on floating; they are therefore able to run even in deep water, without touching the floor. This is quite difficult to start with but after some training to find their balance, it is great. Even better for most injuries is to run on the floor of more shallow water, since the athlete is ‘pushing off’, albeit with a slight delay – like ‘space walking’. This allows training without a float jacket but I recommend some thin shoes to avoid blisters. An athlete can burn as much energy in water exercises as in any other training but must be careful to control dehydration, which may not be felt in the same way as when running on a road.

Water exercising is recommended for obese unfit people but they may not wish to join a group of people dressed in swimsuits, so their likely compliance must be considered. However, with the huge number of public pools around the country this type of training is accessible to most.

SWIMMING

Swimming is often recommended as an alternative training method for people with injuries of the lower limbs and back problems, but for upper limb injuries and neck injuries it may be contra-indicated.
The technique of swimming is very demanding and often hampers its aerobic and anaerobic effects and thus the time spent in the water. To swim for 30 minutes requires a well-developed technique. Even though there is no direct impact, swimming may cause problems if the training is not precisely defined: it is important to recommend or restrict different techniques of swimming for different injuries. For example, swimming the breaststroke can exacerbate knee injuries such as medial meniscus tears, osteoarthritis, anterior knee pain and most shoulder injuries. Most swimming techniques will provoke sub-acromial impingement and patients with multidirectional instability in the shoulder should not be prescribed swimming. Low back pain and neck pain may well be aggravated if the athlete does not lower the head down into the water in the swimming stride but looks up, protecting the face or eyes from the chlorine but hyper-extending the cervical and lumbar spine. Such simple mistakes often mean that the athlete does not comply with the programme.

The advice to include swimming in a training programme must be supported by a detailed history of the injured athlete’s abilities and restrictions. For an elderly elite swimmer or a triathlete with an Achilles tendon injury, swimming is an excellent alternative to running on roads.

BICYCLING

Cycling, either on a stationary or a normal bicycle, can maintain and improve aerobic and anaerobic endurance and muscle strength in the legs, with low eccentric impact. It is a good way of initiating a fitness programme for untrained, elderly and overweight patients. Cycling can be prescribed for injuries where running is impossible. The leg muscles will be trained differently, depending on the saddle height, pedal position and handlebar shape and position. Varying these factors will stress specific muscle groups: for example, an athlete with a cast on a lower limb, perhaps for Achilles tendon repair, can place the pedal under the heel and cycle. People with femuro-patellar pain or hip osteoarthritis will often require a higher saddle, while those suffering a rupture of the hamstring muscles or back pain will need an upright position and a higher handlebar, and those with carpal tunnel syndrome must avoid gripping the handlebar too hard. A stationary bicycle at a sports clinic makes it possible to test and adjust seating position, and advise on training individually.

There are very few injuries where you cannot cycle and cycling is a very good training alternative for all ages. Cycling can be done over a distance, in intervals, in classes or individually; resistance and pace can be altered to suit most athletes. Cycling in the countryside is lovely but can be more demanding, depending on the terrain, weather and traffic conditions. As for other exercise prescriptions, the programme and progression must be detailed.

MOUNTAIN BIKING

Mountain biking is an advanced form of cycling training that can be recommended to some more adventurous
athletes. For young and fit cyclists, orienteerers, skiers and players in most team sports, mountain biking is an
excellent choice when suffering most types of injuries. Both the leg and arm muscles will be put under very
high stress when riding in hilly terrain but the eccentric impact is low. Mountain biking will maintain or increase
aerobic and anaerobic endurance, muscle strength in the legs, arms and upper part of the body and general
balance.

The position of the handlebar and the saddle height is somewhat limited by the fact that the cyclist must have a low centre of gravity; toe clips are often necessary. Mountain biking has its limitations: the bike is expensive and town dwellers may not have access to appropriate and available countryside. It is also slightly dangerous for inexperienced cyclists – most injuries are caused by falling off the bike. It is very important for the cyclist to adapt their speed to their capacity.

Cycling in hilly terrain gives mountain biking a natural interval training profile but it is physically very demanding. Helmet, gloves, appropriate clothing and knee protection should always be worn and the bike must be good–quality, with efficient brakes.

SKATEBOARDING, ROLLER-SKATING AND WIND-SURFING

These activities can help athletes maintain or increase body posture, proprioception, core stability and muscle function with low impact, subject to good technique and the avoidance of new injuries from unnecessary falls. These kinds of activities have become very popular for younger people and must be considered as alternative training methods for fit athletes.

The equipment is quite expensive but can be rented. These activities require very good co-ordination and muscle strength and should be prescribed to already fit individuals, for example soccer or rugby players, but cannot be recommended for those with poor balance and co-ordination. For example, for those with shin splints or who are recovering from knee surgery, as an alternative to bicycling and running, roller-skating is very efficient endurance training to develop quadriceps muscle strength. For ice-hockey players, roller-skating is a natural way of exercising during pre-season training. Both skateboarding and wind-surfing are excellent balance exercises for different seasons for injured martial arts athletes and gymnasts. All these sports should preferably be performed in controlled environments, with instructors.

CROSS-TRAINING

Cross-training refers to varied training, combining different sports like cycling, running, swimming, skiing, skating and workouts and gives all-round training. Any of these sports can be left out if necessary for rehabilitation. A six-month programme, mixing these activities in reasonable proportions over each week, with gradual progression, will give efficient fitness training.

TENNIS AND OTHER RACKET SPORTS

Racket sports, such as tennis, squash, racketball and badminton can sometimes be prescribed as alternative training for general fitness development and during convalescence for a number of injuries. Modifications may be required: for example, a sore knee may allow baseline tennis play on grass but not allow sprints and turns on a hard court. A stiff shoulder may not allow overhead serves but be perfectly all right for baseline play. Elbow injuries, such as lateral epicondylitis, may require double backhands to avoid pain. Double or mixed games do not involve the same amount of running as singles. Squash is more demanding for the wrist and elbow than the shoulder; badminton is very demanding for the Achilles tendon but may be played with a non-dominant shoulder injury. Thus, instead of resting completely, a keen player can maintain parts of their play until treatment and rehabilitation is completed. Meeting and playing with friends is also very important for encouraging the return to sport.

GOLF

Golf is excellent, low-impact exercise for all age groups, providing a pleasant social environment and general well-being. Golf can be prescribed during convalescence from most injuries and disorders that only allow walking. Even with Cross-training is a great way to regain functional fitness at the end of rehabilitation
Maintain a ‘not too much too soon’ policy and most racket sports are fairly risk free severe hip osteoarthritis, a motorised cart may be used to cover the main bulk of the distance. A left knee injury may require the golfer to open their stance slightly. A painful shoulder may decrease the power at tee-off but perhaps precision will improve. People with back injuries should take individual advice, since the rotational movements are quite demanding.

The five-kilometre walk, combined with the thrill of hitting the ball over varied courses, excites most people. Technique is important and most club professionals will assist with advice. Professional players in many sports play golf and courses can be found everywhere.

SOCCER, RUGBY AND OTHER CONTACT SPORTS

Most contact sports have an undeserved reputation for being dangerous. Even though injuries do occur and are sometimes severe, especially in the professional game, the rate of injury per hour of training and playing is relatively low. At a recreational level, players can agree to avoid unnecessary and dangerous body contact: choosing non-contact netball instead of basketball, agreeing to keep hockey sticks below the waist, using proper protection and so on, can keep the injury rate low.

It can be difficult safely to stage the return to playing: being out of rugby for six months and then playing a full 80-minute game is very risky. Going back must be stepped: running in a straight line, then faster running, side-stepping, turning, improving core stability and posture, light contact and passing, full contact, playing the last 20 minutes in a reserves’ game and so on. Such staging requires good teamwork but is more difficult for recreational players who have no access to coaches or team medics.

Many of the injuries we see in contact sports are caused by insufficient rehabilitation from previous injuries. The aim must first be to restore balanced limb performance and then an appropriate and sportspecific level of fitness. One way to achieve this is to compile a functional score, which includes a subjective score, an objective examination and the results of simple functional tests. The problem is that each sport and each level of performance requires its own score.

WORKING-OUT AND GYM TRAINING

Working-out, aerobics and similar activities are excellent, and often essential, rehabilitation methods and useful alternatives during rehabilitation of many injuries. Gym training, with a variety of fixed stations for weight training, has become popular recreational exercise. It is also used for basic pre-season training in almost every sport. There is no better way to learn functional anatomy than to work-out the muscle groups step by step in a gym.

No equipment is better than the skills of the instructor. Working-out with weights is technically difficult and there are lots of pitfalls that need to be considered in close collaboration with a licensed instructor and access to appropriate training equipment. Training should start with an objective function test, so a reasonable measure of progress can be made. Beginners usually start with an individual training programme based on six to ten exercises. After working-out a few times at low resistance and learning the specific movements, the training is documented, inclu ding what kind of
equipment is used, how many repetitions and sets and how much resistance. Warming up, on a bike or treadmill, is essential before strength training. Depending on any underlying problems, such as osteoporosis or injury, such as a temporary fragile cruciate ligament graft, the programme must be modified over time.

HIDDEN HOME EXERCISES

Even for the general, sedentary, non-sporty population, exercise is an essential part of well-being. Exercise is also the ‘drug’ prescribed for a number of major health problems such as high blood pressure, heart insufficiency, diabetes, asthma, obesity, osteoporosis, rheumatoid arthritis and multiple sclerosis. Although for each of these disorders there are exercise alternatives that may be prescribed under the close supervision of a specialist doctor, we should be wary of sending unmotivated people to gyms or fitness centres where they feel out of place and uncomfortable. We should not under estimate the negative effects of how modern society has turned many into crisp-eating, soap-watching, coach potatoes.

On the other hand, we should not underestimate the positive effect of everyday activities. For example (and this applies to both sexes), one to two hours of vigorous weekly cleaning of a normal house will force a middle-aged sedentary person to use 70 to 80 per cent of their maximal oxygen uptake, equivalent to running for 45 minutes at a good pace. Cleaning windows manually is excellent rotator cuff training after shoulder injuries; vacuum cleaning requires core stability and posture; washing dishes in warm water is excellent for a healed radius fracture. There are many, many other examples: running up and down stairs, standing on one leg on a wobble board while brushing your teeth, stretching out in the shower, cutting the hedges, mowing the lawn, walking or jogging the dog, jumping off the bus one stop away from the office, using stairs instead of lifts. We neglect many of these things (if we can) during the week, then we spend money and energy on a one-hour run on a treadmill and gym training. Who needs exercise if you are running after three small children all day or taking the dog out once a day?

Exercise on prescription is not new. A Swedish doctor who lived in Enkoping in the early twentieth century gave detailed prescriptions: six walks a day around the park, three sit-downs and stand-ups from each of the park benches and so on. In ancient literature, from the Egyptians and Greeks to the Chinese, exercise is named as a basic and essential ingredient of life. If we sit still we die!

Without sounding like an old schoolmarm, I do think we should go back to some of these basic
ideas, to avoid further deterioration of sedentary people’s fitness levels and help motivate injured
athletes by prescribing a balanced diet of alternative exercises.

Of course one should take precautions before exercising and one should know one’s limit. If you are unsure of your condition, do give us a call at +65 9724 1219 (24 hrs) to make an appointment for a physical assessment.